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Witsch J, Cao Q, Song JW, Luo Y, Sloane KL, Rothstein A, Favilla CG, Cucchiara BL, Kasner SE, Messé SR, Choi HA, McCullough LD, Mayer SA, Gusdon AM. Sex Differences in Perihematomal Edema Volume and Outcome After Intracerebral Hemorrhage. Neurocrit Care 2024; 41:208-217. [PMID: 38379104 DOI: 10.1007/s12028-024-01945-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/12/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Although larger hematoma volume is associated with worse outcome after intracerebral hemorrhage (ICH), the association between perihematomal edema (PHE) volume and outcome remains uncertain, as does the impact of sex on PHE and outcome. Here we aimed to determine whether larger PHE volume is associated with worse outcome and whether PHE volume trajectories differ by sex. METHODS We conducted a post hoc analysis of the Factor VIIa for Acute Hemorrhagic Stroke Treatment (FAST) trial, which randomized patients with ICH to receive recombinant activated factor VIIa or placebo. Computerized planimetry calculated PHE and ICH volumes on serial computed tomography (CT) scans (at baseline [within 3 h of onset], at 24 h, and at 72 h). Generalized estimating equations examined interactions between sex, CT time points, and FAST treatment arm on PHE and ICH volumes. Mixed and multivariable logistic models examined associations between sex, PHE, and outcomes. RESULTS A total of 781 patients with supratentorial ICH (mean age 65 years) were included. Compared to women (n = 296), men (n = 485) had similar median ICH (14.9 vs. 13.6 mL, p = 0.053) and PHE volumes (11.1 vs. 10.5 mL, p = 0.56) at baseline but larger ICH and PHE volumes at 24 h (19.0 vs. 14.0 mL, p < 0.001; 22.2 vs. 15.7 mL, p < 0.001) and 72 h (16.0 vs. 11.8 mL, p < 0.001; 28.7 vs. 19.9 mL, p < 0.001). Men had higher absolute early PHE expansion (p < 0.001) and more hematoma expansion (growth ≥ 33% or 6 mL at 24 h, 33% vs. 22%, p < 0.001). An interaction between sex and CT time points on PHE volume (p < 0.001), but not on ICH volume, confirmed a steeper PHE trajectory in men. PHE expansion (per 5 mL, odds radio 1.19, 95% confidence interval 1.10-1.28), but not sex, was associated with poor outcome. CONCLUSIONS Early PHE expansion and trajectory in men were significantly higher. PHE expansion was associated with poor outcomes independent of sex. Mechanisms leading to sex differences in PHE trajectories merit further investigation.
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Affiliation(s)
- Jens Witsch
- Department of Neurology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
| | - Quy Cao
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jae W Song
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Yunshi Luo
- Graduate School of Education, University of Pennsylvania, Philadelphia, PA, USA
| | - Kelly L Sloane
- Department of Neurology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Aaron Rothstein
- Department of Neurology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Christopher G Favilla
- Department of Neurology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Brett L Cucchiara
- Department of Neurology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Scott E Kasner
- Department of Neurology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Steve R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Huimahn A Choi
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Louise D McCullough
- Department of Neurobiology & Anatomy, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Stephan A Mayer
- Departments of Neurology and Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Aaron M Gusdon
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
- Department of Neurobiology & Anatomy, University of Texas Health Science Center at Houston, Houston, TX, USA
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2
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Apostolaki-Hansson T, Kremer C, Pihlsgård M, Petersson J, Norrving B, Ullberg T. Diverging Trends in Survival and Functional Outcome between Males and Females after Intracerebral Hemorrhage. Neuroepidemiology 2024:1-11. [PMID: 38981450 DOI: 10.1159/000539958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/11/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Compared to ischemic stroke, sex differences in patient outcomes following intracerebral hemorrhage (ICH) are underreported. We aimed to determine sex differences in mortality and functional outcomes in a large, unselected Swedish cohort. METHODS In this observational study, data on 22,789 patients with spontaneous ICH registered in the Swedish Stroke Register between 2012 and 2019 were used to compare sex differences in 90-day mortality and functional outcome using multivariable Cox and logistic regression analyses, adjusting for relevant confounders. Multiple imputation was used to impute missing data. RESULTS The crude 90-day mortality rate was 36.7% in females (3,820/10,405) and 31.7% in males (3,929/12,384) (female hazard ratio [HR] 1.20 95% confidence interval [CI]: 1.15-1.25). In multivariable analysis, the HR for 90-day mortality following ICH in females was 0.89 (95% CI: 0.85-0.94). Age was an important driving factor for the effect of sex on mortality. After adjustment for age, vascular risk factors, and stroke severity, the 90-day functional outcome in pre-stroke independent patients was worse in females compared to males (odds ratio: 1.27 95% CI: 1.16-1.40). CONCLUSION In this large observational study, despite lower 90-day mortality, the female sex was independently associated with a worse functional outcome compared to males after ICH, even after adjusting for significant covariates. These diverging trends have not been previously reported for ICH. Given the observational design, our findings should be interpreted with caution, thus further external validation is warranted.
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Affiliation(s)
- Trine Apostolaki-Hansson
- Department of Neurology, Skåne University Hospital, Malmö/Lund, Lund, Sweden
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Christine Kremer
- Department of Neurology, Skåne University Hospital, Malmö/Lund, Lund, Sweden
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Mats Pihlsgård
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Jesper Petersson
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Bo Norrving
- Department of Neurology, Skåne University Hospital, Malmö/Lund, Lund, Sweden
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Teresa Ullberg
- Department of Neurology, Skåne University Hospital, Malmö/Lund, Lund, Sweden
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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3
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Sterenstein A, Garg R. The impact of sex on epidemiology, management, and outcome of spontaneous intracerebral hemorrhage (sICH). J Stroke Cerebrovasc Dis 2024; 33:107755. [PMID: 38705497 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/25/2024] [Accepted: 05/01/2024] [Indexed: 05/07/2024] Open
Abstract
OBJECTIVE Data on sex differences in spontaneous intracerebral hemorrhages are limited. METHODS An automated comprehensive scoping literature review was performed using PubMed and Scopus. Articles written in English about spontaneous intracerebral hemorrhage and sex were reviewed. RESULTS Males experience spontaneous intracerebral hemorrhage more frequently than females, at younger ages, and have a higher prevalence of deep bleeds compared to females. Risk factors between sexes vary and may contribute to differing incidences and locations of spontaneous intracranial hemorrhage. Globally, females receive less aggressive care than males, likely impacting survival. CONCLUSIONS Epidemiology, risk factors, and treatment of spontaneous intracranial hemorrhage vary by sex, with limited and oftentimes conflicting data available. Further research into the sex-based differences of spontaneous intracranial hemorrhage is necessary for clinicians to better understand how to evaluate and guide treatment in the future.
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Affiliation(s)
- Andrea Sterenstein
- Rush University Medical Center, Division of Critical Care Neurology, Department of Neurological Sciences.
| | - Rajeev Garg
- Rush University Medical Center, Division of Critical Care Neurology, Department of Neurological Sciences
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4
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Owais SB, Bulwa ZB, Ammar FE. Differences in stroke clinical presentation among sexes. J Stroke Cerebrovasc Dis 2024; 33:107807. [PMID: 38851548 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 05/03/2024] [Accepted: 06/05/2024] [Indexed: 06/10/2024] Open
Abstract
INTRODUCTION There are sex-based differences in stroke epidemiology, treatment, and outcomes. In this manuscript, we discuss the differences that exist in the clinical presentation of acute stroke among sexes. DISCUSSION We present the differences in stroke presentation among sexes including age at the time of presentation, severity of stroke on presentation, and stroke type and location. We discuss the atypical clinical presentations, explore the radiographic findings on presentation (including location, infarct core volume, the impact of collateral circulation, hematoma location in intracranial hemorrhage), and discuss differences in time elapsed between symptom onset and management amongst sexes. CONCLUSION Differences exist in stroke clinical presentation amongst sexes. These disparities have public health implications, and as they become better understood, impact awareness campaigns in both the public and healthcare communities.
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Affiliation(s)
- Syeda B Owais
- Department of Neurology, Neurocritical Care Department of Neurology and Rehabilitation, University of Illinois Chicago, Chicago, IL 60612, United States
| | - Zachary B Bulwa
- Department of Neurology, NorthShore University HealthSystem, Evanston, IL, United States
| | - Faten El Ammar
- Department of Neurology, Neurocritical Care Department of Neurology and Rehabilitation, University of Illinois Chicago, Chicago, IL 60612, United States.
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Ali M, van Etten ES, Akoudad S, Schaafsma JD, Visser MC, Ali M, Cordonnier C, Sandset EC, Klijn CJM, Ruigrok YM, Wermer MJH. Haemorrhagic stroke and brain vascular malformations in women: risk factors and clinical features. Lancet Neurol 2024; 23:625-635. [PMID: 38760100 DOI: 10.1016/s1474-4422(24)00122-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/18/2024] [Accepted: 03/14/2024] [Indexed: 05/19/2024]
Abstract
Haemorrhagic stroke is a severe condition with poor prognosis. Biological sex influences the risk factors, presentations, treatment, and patient outcomes of intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and vascular malformations. Women are usually older at onset of intracerebral haemorrhage compared with men but have an increased risk of aneurysmal subarachnoid haemorrhage as they age. Female-specific factors such as pregnancy, eclampsia or pre-eclampsia, postmenopausal status, and hormone therapy influence a woman's long-term risk of haemorrhagic stroke. The presence of intracranial aneurysms, arteriovenous malformations, or cavernous malformations poses unique clinical dilemmas during pregnancy and delivery. In the absence of evidence-based guidelines for managing the low yet uncertain risk of haemorrhagic stroke during pregnancy and delivery in women with vascular malformations, multidisciplinary teams should carefully assess the risks and benefits of delivery methods for these patients. Health-care providers should recognise and address the challenges that women might have to confront when recovering from haemorrhagic stroke.
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Affiliation(s)
- Mariam Ali
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands.
| | - Ellis S van Etten
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
| | - Saloua Akoudad
- Department of Neurology, University Medical Centre Groningen, Groningen, Netherlands
| | - Joanna D Schaafsma
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marieke C Visser
- Department of Neurology, Amsterdam University Medical Centre, Location AMC, Amsterdam, Netherlands
| | - Mahsoem Ali
- Department of Surgery, Amsterdam University Medical Centre, Location VUmc, Amsterdam, Netherlands
| | - Charlotte Cordonnier
- University Lille, Inserm, CHU Lille, UMR-S1172, Lille Neuroscience and Cognition, Lille, France
| | - Else Charlotte Sandset
- Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway; The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Ynte M Ruigrok
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marieke J H Wermer
- Department of Neurology, University Medical Centre Groningen, Groningen, Netherlands
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6
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Witsch J, Cao Q, Song JW, Luo Y, Sloane KL, Rothstein A, Favilla CG, Cucchiara BL, Kasner SE, Messé SR, Choi HA, McCullough LD, Mayer SA, Gusdon AM. Sex differences in perihematomal edema volume and outcome after intracerebral hemorrhage. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.28.23296302. [PMID: 37808630 PMCID: PMC10557833 DOI: 10.1101/2023.09.28.23296302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Objective To determine whether in patients with intracerebral hemorrhage (ICH) perihematomal edema (PHE) volume trajectories differ by sex. Methods We conducted a post-hoc analysis of the Factor-VII-for-Acute-Hemorrhagic-Stroke-Treatment (FAST) trial that randomized patients with ICH to receive recombinant activated Factor VIIa or placebo. Computerized planimetry calculated PHE and ICH volumes on serial CT scans (at baseline [within 3 hours of onset], at 24, and at 72 hours). Generalized estimating equations examined interactions between sex, CT-timepoints, and FAST treatment-arm on PHE and ICH volumes. Mixed and multivariate logistic models examined associations between sex, PHE, and outcomes. Results 781 with supratentorial ICH (mean age 65 years) were included. Compared to women (n=296), men (n=485) had similar median ICH (14.9 versus 13.6 ml, p=0.053), and PHE volumes (11.1 versus 10.5 ml, p=0.56) at baseline but larger ICH and PHE at 24 hours (19.0 versus 14.0, p<0.001; 22.2 versus 15.7, p<0.001) and 72 hours (16.0 versus 11.8, p<0.001; 28.7 versus 19.9, p<0.001). Men had higher absolute PHE expansion (p<0.001), and more hematoma expansion (growth ≥33% or 6 mL at 24 hours, 33% versus 22%, p<0.001). An interaction between sex and CT-timepoints on PHE (p<0.001) but not on ICH volumes confirmed a steeper PHE trajectory in men. PHE expansion (per 5mL, odds radio, 1.19, 95%-confidence interval 1.10-1.28), but not sex, was associated with poor outcome. Conclusions PHE expansion and trajectory in men were significantly higher. PHE expansion was associated with poor outcomes independent of sex. Mechanisms leading to sex differences in PHE trajectories merit further investigation. What is already known on this topic Prior research has reported sex differences in intracerebral hemorrhage (ICH) characteristics and some studies suggest worse outcome after ICH in women. However, we do not have a good understanding whether there are sex differences in perihematomal edema (PHE) volume trajectories, or whether sex, independent of confounders, is associated with poor after ICH. What this study adds In this post-hoc analysis of 781 patients with supratentorial ICH from the Factor-VII-for-Acute-Hemorrhagic-Stroke-Treatment (FAST) trial in which patients underwent brain CT imaging time-locked to symptom onset (within 3 hours of symptom onset, at 24 hours, and at 72 hours), men compared to women had similar ICH and PHE volumes at baseline, but larger ICH expansion and PHE expansion on follow up imaging. The PHE but not the ICH volume trajectory across scans was significantly higher in men than in women. While PHE expansion was associated with poor outcome at 90 days, outcome between the sexes was similar at 90 days, and sex was not associated with outcome. How this study might affect research practice or policy The finding of heightened early PHE and ICH expansion in men may inform study design, patient recruitment strategies, and pre-specification of subgroup analyses in future interventional trials. The findings of this study also suggest that focusing on sex-specific factors may allow novel mechanistic insight into PHE, a major cause of secondary injury and poor outcome after ICH.
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7
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Abstract
Differences exist between genders in intracerebral hemorrhage cause, epidemiology, and outcomes. These gender differences are in part attributable to physiologic differences; however, demographic, social/behavioral risk factors, along with health care system variation and potential family and/or clinician bias play a role as well. These factors vary from region to region and interact, making comprehensive and definitive conclusions regarding sex differences a challenging task. Differences between the genders in intracerebral hemorrhage epidemiology and extensive differences in underlying pathophysiology, intervention, risk factors, and outcome are all discussed.
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Affiliation(s)
- Nicholas Dykman Osteraas
- Department of Neurological Sciences, Division of Cerebrovascular Diseases, Rush University Medical Center, 1725 West Harrison Street Suite 118, Chicago, IL 60612, USA.
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8
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Singh SK, McCullough L. Sex Differences in the Evaluation and Treatment of Stroke. Handb Exp Pharmacol 2023; 282:77-106. [PMID: 37460659 DOI: 10.1007/164_2023_682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
There are differences in the prevalence and strength of risk factors in women, along with sex-specific risk factors such as pregnancy. Women have a higher lifetime risk of stroke compared to men, with worse outcomes including higher rates of death and disability. We have made strides in the identification of sex-specific risk factors but with the paucity of sex-specific end points in clinical trials, stroke treatment and research are hindered.
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Affiliation(s)
- Sonia K Singh
- McGovern Medical School, UTHealth Houston, Houston, TX, USA
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9
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Broberg E, Hjalmarsson C, Setalani M, Milenkoski R, Andersson B. Sex Differences in Treatment and Prognosis of Acute Intracerebral Hemorrhage. J Womens Health (Larchmt) 2023; 32:102-108. [PMID: 35960812 DOI: 10.1089/jwh.2021.0577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background: Intracerebral hemorrhage (ICH) accounts for 10%-15% of all stroke cases and is associated with a high risk of death and disability. Prior studies in ischemic stroke have demonstrated a less favorable outcome in women compared with men, but there is a paucity of data regarding differences in outcome by sex in ICH. The aim of the present study was to investigate possible sex differences in acute care and the 3-months follow-up of patients with ICH. Methods: Data were collected from the Swedish National Stroke Registry (Riksstroke). Demographic and baseline characteristics were collected, based on in-hospital data and data from 3-months follow-up. Results: Variables of interest were collected from 1,403 patients. Women (45.1%) were significantly older than men, with a mean age ± standard deviation of 77 ± 13years, versus 71 ± 14 years, p < 0.01. On admission, the ICH severity was similar in men and women. There was no significant association between sex and reception of neuroimaging or neurosurgery. Women were less likely to be treated in a stroke unit (80.8% vs. 85.3%, p = 0.03), or discharged to home (51.5% vs. 63.4%, p < 0.01). At 3-months follow-up, there were no sex-related differences regarding dependence, post-ICH self-reported depression, or case fatality. Conclusions: Women were less likely to be treated in a stroke unit, and were less often discharged to home. However, no significant differences in 3-month functional outcome or survival between men and women with ICH were found in this study.
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Affiliation(s)
- Erika Broberg
- Department of Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Clara Hjalmarsson
- Department of Cardiology, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mehrnoush Setalani
- Department of Geriatric, Neurology and Rehabilitation, Kungälv Hospital, Kungälv, Sweden
| | | | - Björn Andersson
- Department of Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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10
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Muacevic A, Adler JR, Stead TS, Mangal R, Ganti L. Frontal Lobe Hemorrhage With Surrounding Edema and Subarachnoid Hemorrhage. Cureus 2022; 14:e31345. [PMID: 36514615 PMCID: PMC9741553 DOI: 10.7759/cureus.31345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2022] [Indexed: 11/12/2022] Open
Abstract
We report the case of an 81-year-old woman who presented with a left hemineglect, a rightward gaze preference, and baseline disorientation. Her National Institutes of Health Stroke Score was 4. Her medical history was significant for dementia, osteoporosis, dyslipidemia, and a previous stroke. CT revealed a right-sided frontal lobe hemorrhage with surrounding edema and subarachnoid hemorrhage. Laboratory evaluation was significant for leukocytosis. The etiologies, clinical presentation, and diagnosis of this often devastating type of stroke are presented. While she did have a significant neurologic deficit (neglect), she was able to remain alert and protect her airway. Her hospital course consisted of observation in the ICU and blood pressure management. The case illustrates that intracerebral hemorrhage (ICH) can sometimes present indolently and does not always require surgical intervention.
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11
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Carcel C, Caso V, Aguiar de Sousa D, Sandset EC. Sex differences in neurovascular disorders. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 164:69-99. [PMID: 36038210 DOI: 10.1016/bs.irn.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Neurovascular disorders is a heterogenous group of diseases, including one of the most time critical disorders in emergency medicine; stroke. Sex differences are extensively described in neurovascular disorders, ranging from differences in symptom presentation, risk factors, treatment and outcomes. For example, women with stroke, more often present with generalized weakness, reduced consciousness and headache than men. Furthermore, there are differences in risk factors, outcomes and in the effect of secondary prevention. Women have a higher risk of cerebral venous thrombosis and developing cerebral aneurysms. In general, women have been underrepresented in trials on neurovascular disorders. This chapter provides an extensive overview of sex differences in stroke in general and in the differences specially seen in ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage and in cerebral venous thrombosis.
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Affiliation(s)
- Cheryl Carcel
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Sydney School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital University of Perugia, Perugia, Italy
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital, Lisbon, Portugal; CEEM and Institute of Anatomy, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway; The Norwegian Air Ambulance Foundation, Oslo, Norway.
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Wang SSY, Bögli SY, Nierobisch N, Wildbolz S, Keller E, Brandi G. Sex-Related Differences in Patients' Characteristics, Provided Care, and Outcomes Following Spontaneous Intracerebral Hemorrhage. Neurocrit Care 2022; 37:111-120. [PMID: 35386067 PMCID: PMC9283357 DOI: 10.1007/s12028-022-01453-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sex-related differences in patients with spontaneous, non-traumatic intracerebral hemorrhage (ICH) are poorly investigated so far. This study elucidates whether sex-related differences in ICH care in a neurocritical care setting exist, particularly regarding provided care, while also taking patient characteristics, and outcomes into account. METHODS This retrospective single center study includes all consecutive patients with spontaneous ICH admitted to the neurocritical care unit in a 10-year period. Patients' demographics, comorbidities, symptoms at presentation, radiological findings, surgical and medical provided care, intensive care unit mortality and 12 month-mortality, and functional outcome at discharge were compared among men and women. RESULTS Overall, 398 patients were included (male = 198 and female = 200). No differences in demographics, Charlson Comorbidity Index (CCI), symptoms at presentation, radiological findings, intensive care unit mortality and 12-month mortality were observed among men and women. Men received an external ventricular drain (EVD) for hydrocephalus-therapy significantly more often than women, despite similar location of the ICH and radiographic parameters. In the multivariate analysis, EVD insertion was independently associated with male sex (odds ratio 2.82, 95% confidence interval 1.61-4.95, P < 0.001) irrespective of demographic or radiological features. Functional outcome after ICH as assessed by the modified Rankin scale, was more favorable for women (P = 0.044). CONCLUSIONS Sex-related differences in patients with ICH regarding to provided neurosurgical care exist. We provide evidence that insertion of EVD is associated with male sex, disregarding clear reasoning. A sex-bias as well as social factors may play a significant role in decision-making for the insertion of an EVD.
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Affiliation(s)
- Sophie Shih-Yüng Wang
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University Tübingen, Hoppe-Seyler-Strasse 3, 72070, Tübingen, Germany.
- Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland.
| | - Stefan Yu Bögli
- Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Nathalie Nierobisch
- Department of Diagnostic and Interventional Radiology, University Hospital of Zurich, Zurich, Switzerland
| | - Stella Wildbolz
- Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Emanuela Keller
- Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
- Department of Neurosurgery and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Giovanna Brandi
- Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
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13
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Grundtvig J, Ovesen C, Steiner T, Carcel C, Gaist D, Christensen L, Marstrand J, Meden P, Rosenbaum S, Iversen HK, Kruuse C, Christensen T, Ægidius K, Havsteen I, Christensen H. Sex-Differences in Oral Anticoagulant-Related Intracerebral Hemorrhage. Front Neurol 2022; 13:832903. [PMID: 35309585 PMCID: PMC8927802 DOI: 10.3389/fneur.2022.832903] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/31/2022] [Indexed: 12/21/2022] Open
Abstract
Introduction and Aim Data remain limited on sex-differences in patients with oral anticoagulant (OAC)-related intracerebral hemorrhage (ICH). We aim to explore similarities and differences in risk factors, acute presentation, treatments, and outcome in men and women admitted with OAC-related ICH. Method This study was a retrospective observational study based on 401 consecutive patients with OAC-related ICH admitted within 24 h of symptom onset. The study was registered on osf.io. We performed logarithmic regression and cox-regression adjusting for age, hematoma volume, Charlson Comorbidity Index (CCI), and pre-stroke modified Ranking Scale (mRS). Gender and age were excluded from CHA2DS2-VASc and CCI was not adjusted for age. Results A total of 226 men and 175 women were identified. More men were pre-treated with vitamin K-antagonists (73.5% men vs. 60.6% women) and more women with non-vitamin K-antagonist oral anticoagulants (26.5% men vs. 39.4% women), p = 0.009. Women were older (mean age 81.9 vs. 76.9 years, p < 0.001). CHA2DS2-VASc and CCI were similar in men and women. Hematoma volumes (22.1 ml in men and 19.1 ml in women) and National Institute of Health Stroke Scale (NIHSS) scores (13 vs. 13) were not statistically different, while median Glasgow Coma Scale (GCS) was lower in women, (14 [8;15] vs. 14 [10;15] p = 0.003). Women's probability of receiving reversal agents was significantly lower (adjusted odds ratio [aOR] = 0.52, p = 0.007) but not for surgical clot removal (aOR = 0.56, p = 0.25). Women had higher odds of receiving do-not-resuscitate (DNR) orders within a week (aOR = 1.67, p = 0.04). There were no sex-differences in neurological deterioration (aOR = 1.48, p = 0.10), ability to walk at 3 months (aOR = 0.69, p = 0.21) or 1-year mortality (adjusted hazard ratio = 1.18, p = 0.27). Conclusion Significant sex-differences were observed in age, risk factors, access to treatment, and DNRs while no significant differences were observed in comorbidity burden, stroke severity, or hematoma volume. Outcomes, such as adjusted mortality, ability to walk, and neurological deterioration, were comparable. This study supports the presence of sex-differences in risk factors and care but not in presentation and outcomes.
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Affiliation(s)
- Josefine Grundtvig
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- *Correspondence: Josefine Grundtvig
| | - Christian Ovesen
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Thorsten Steiner
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Cheryl Carcel
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - David Gaist
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Louisa Christensen
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Marstrand
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Per Meden
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sverre Rosenbaum
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Helle K. Iversen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - Christina Kruuse
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Herlev Hospital, Copenhagen, Denmark
| | | | - Karen Ægidius
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Inger Havsteen
- Department of Radiology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Hanne Christensen
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14
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Abstract
Women face a disproportionate burden of stroke mortality and disability. Biologic sex and sociocultural gender both contribute to differences in stroke risk factors, assessment, treatment, and outcomes. There are substantial differences in the strength of association of stroke risk factors, as well as female-specific risk factors. Moreover, there are differences in presentation, response to treatment, and stroke outcomes in women. This review outlines current knowledge of impact of sex and gender on stroke, as well as delineates research gaps and areas for future inquiry.
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Affiliation(s)
- Kathryn M. Rexrode
- Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Tracy E. Madsen
- Division of Sex and Gender in Emergency Medicine, Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI; Department of Epidemiology, Brown University School of Public Health, Providence RI
| | - Amy Y. X. Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cheryl Carcel
- Neurology Program, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Judith H. Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Eliza C. Miller
- Division of Stroke and Cerebrovascular Disease, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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15
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de Miguel-Yanes JM, Lopez-de-Andres A, Jimenez-Garcia R, Hernandez-Barrera V, de Miguel-Diez J, Méndez-Bailón M, Pérez-Farinós N, Muñoz-Rivas N, Carabantes-Alarcon D, López-Herranz M. Incidence and Outcomes of Hemorrhagic Stroke among Adults in Spain (2016-2018) According to Sex: A Retrospective, Cohort, Observational, Propensity Score Matched Study. J Clin Med 2021; 10:jcm10163753. [PMID: 34442046 PMCID: PMC8397207 DOI: 10.3390/jcm10163753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/13/2021] [Accepted: 08/20/2021] [Indexed: 12/12/2022] Open
Abstract
(1) Background: We aim to analyze sex differences in the incidence, clinical characteristics and in-hospital outcomes of hemorrhagic stroke (HS) in Spain (2016–2018) using the National Hospital Discharge Database. (2) Methods: Retrospective, cohort, observational study. We estimated the incidence of HS in men and women. We analyzed comorbidity, treatments, procedures, and hospital outcomes. We matched each woman with a man by age, type of HS and medical conditions using propensity score matching. (3) Results: HS was coded in 57,227 patients aged ≥18 years (44.3% women). Overall, men showed higher incidence rates (57.3/105 vs. 43.0/105; p < 0.001; IRR = 1.60; 95% CI: 1.38–1.83). Women suffered more subarachnoid hemorrhages (25.2% vs. 14.6%), whereas men more often had intracerebral hemorrhages (55.7% vs. 54.1%). In-hospital mortality (IHM) was higher for intracerebral hemorrhage in both men and women. Women underwent decompressive craniectomy less often than men (5.0% vs. 6.2%; p < 0.001). After matching, IHM among women was higher (29.0% vs. 23.7%; p < 0.001). Increments in age, comorbidity and use of anticoagulants and antiplatelet agents prior to hospitalization were associated were higher IHM, and decompressive craniectomy was associated with lower IHM in both sexes. After multivariable adjustment, women had higher IHM (OR = 1.23; 95% CI: 1.18–1.28). (4) Conclusion: Men had higher incidence rates of HS than women. Women less often underwent decompressive craniectomy. IHM was higher among women admitted for HS than among men.
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Affiliation(s)
- Jose M. de Miguel-Yanes
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense de Madrid, 28040 Madrid, Spain;
| | - Ana Lopez-de-Andres
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain; (R.J.-G.); (D.C.-A.)
- Correspondence: ; Tel.: +34-91-394-1523
| | - Rodrigo Jimenez-Garcia
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain; (R.J.-G.); (D.C.-A.)
| | - Valentin Hernandez-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Universidad Rey Juan Carlos, Alcorcón, 28922 Madrid, Spain;
| | - Javier de Miguel-Diez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense de Madrid, 28040 Madrid, Spain;
| | - Manuel Méndez-Bailón
- Internal Medicine Department, Hospital Universitario Clínico San Carlos, Universidad Complutense de Madrid, 28040 Madrid, Spain;
| | - Napoleón Pérez-Farinós
- Public Health and Psychiatry Department, Faculty of Medicine, Universidad de Málaga, 29010 Málaga, Spain;
| | - Nuria Muñoz-Rivas
- Internal Medicine Department, Hospital Universitario Infanta Leonor, 28031 Madrid, Spain;
| | - David Carabantes-Alarcon
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain; (R.J.-G.); (D.C.-A.)
| | - Marta López-Herranz
- Nursing Department, Faculty of Nursing, Physiotherapy and Podology, Universidad Complutense de Madrid, 28040 Madrid, Spain;
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16
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Carcel C, Reeves M. Under-Enrollment of Women in Stroke Clinical Trials: What Are the Causes and What Should Be Done About It? Stroke 2021; 52:452-457. [PMID: 33493049 DOI: 10.1161/strokeaha.120.033227] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The under-representation of women in clinical trials is a commonly recognized and seemingly intractable problem in many different areas of clinical medicine. Discrepancies in the enrollment of women in clinical trials raises concerns about the generalizability of trial evidence, as well as the potential for reduced access and utilization of new therapies in women. Recent studies confirm that the problem of under-enrollment of women continues to exist in stroke clinical trials, even after accounting for the sex ratio of stroke cases in the underlying population. The origins of these disparities are complex, and there remains a relative dearth of stroke studies that have examined the causes in detail. Although caution should be used when generalizing research findings from studies conducted in other medical conditions including cardiology trials, factors that contribute to lower enrollment in women include the use of specific trial eligibility criteria (eg, older age, presence of specific comorbidities), patient attitudes and beliefs (resulting in less interest and more refusals in women), and potentially implicit biases among study personnel. Beyond a general call to prioritize stroke research in this area, we also recommend the greater use of trial screening logs, the use of qualitative studies to understand patient attitudes and beliefs towards stroke research, avoiding the use of age-based exclusion criteria (eg, >80 years), and increasing the number of women who lead stroke clinical trials.
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Affiliation(s)
- Cheryl Carcel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (C.C.).,The University of Sydney, Sydney School of Public Health, Sydney Medical School, New South Wales, Australia (C.C.)
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing (M.R.)
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